QUESTIONNAIRE YES NO PERSONAL INFORMATION 1 Did your marital status change during the year? 2 Did your address change during the year? 3 Could you be claimed as a dependent on another person's tax return for 2016? DEPENDENTS 4 Were there any changes in dependents? 5 Were any of your unmarried children who might be claimed as dependents 19 years of age or older at the end of 2016? 6 Did you have any children under age 19 or full-time students under age 24 at the end of the year with total investment income in excess of $2,100 or interest/dividend income in excess of $1,050? HEALTHCARE COVERAGE 7 8 Did you and your dependents have healthcare coverage for the full year? Did you receive any of the following IRS Documents? Forms 1095-A, 1095-B or 1095-C. If so, please attach. 9 If you or your dependents did not have healthcare coverage during the year, we will call you with further questions. If you received an exemption certificate, please attach. INCOME 10 Did you receive any unreported tip income of $20 or more in any month? 11 Did you cash any series EE U.S. Savings Bonds issued after 1989 and pay qualified higher education expenses for yourself, your spouse, or your dependent(s)? 12 Did you receive any disability income? 13 Did you have any foreign income or pay any foreign taxes? RETIREMENT PLANS 14 Did you receive a distribution from a retirement plan (401(k), IRA, Roth IRA, Education IRA, SEP, SIMPLE, Qualified Plan, etc.)? 15 Did you convert part or all of your traditional, SEP, or SIMPLE IRA to a Roth IRA? 16 Did you transfer or roll over any amount from one retirement plan to another retirement plan? 17 Did you contribute to a retirement plan (401(k), IRA, Roth IRA, Education IRA, SEP, SIMPLE, Qualified Plan, etc.)? PURCHASES, SALES AND DEBT 18 Did you start a business or farm, purchase rental or royalty property, or acquire an interest in a partnership, S Corporation, Trust, or REMIC? 19 Did you purchase or dispose of any business assets (furniture, equipment, vehicles, real estate, etc.), or convert any personal assets to business use? 20 21 22 Did you buy or sell any stocks, bonds or other investment property? Did you purchase, sell, or refinance your principal home or second home, or did you take a home equity loan? Did you sell or do you plan to sell any dividend generating stocks or mutual funds during the first 60 days of 2016? 23 Did you purchase a home in 2016 and you were overseas on official extended duty? 24 Did you make any residential energy-efficient improvements or purchases involving solar, wind, geothermal, or fuel cell energy sources? 25 Does anyone owe you money which has become uncollectible? 26 Did you have any debts cancelled or forgiven? (Foreclosures and/or short sales) ITEMIZED DEDUCTIONS 27 Did you incur a loss because of damaged or stolen property? 28 Did you work out of town for part of the year? 29 Did you use your car on the job (other than to and from work)? EDUCATION 30 31 Did you receive a distribution from an Education Savings Account or a Qualified Tuition Program? Did you, your spouse, or a dependent incur any tuition expenses that are required to attend a college, university, or vocational school? If so, attach form 1098-T (required). MISCELLANEOUS 32 Do you want to electronically file your tax return? 33 Do you want to allocate $3 to the Presidential Election Campaign Fund? 34 Does your spouse want to allocate $3 to the Presidential Election Campaign Fund? 35 May the IRS discuss your tax return with your preparer? 36 Did you have an interest in or signature or other authority over a financial account in a foreign country, such as a bank account, securities account, or other financial account? 37 Did you receive a distribution from, or were you the grantor of, or transferor to, a foreign trust? 38 Was your home rented out or used for business?
QUESTIONNAIRE (CONTINUED) YES NO MISCELLANEOUS (CONTINUED) 39 Did you have a medical savings account (MSA), a Medicare Advantage MSA, or acquire an interest in an MSA or a Medicare Advantage MSA because of the death of the account holder? Or, were you a policyholder who received payments under a long-term care (LTC) insurance contract or received any accelerated death benefits from a life insurance policy? 40 Did you incur moving expenses due to a change of employment? 41 Did you engage the services of any household employees? 42 Were you notified or audited by either the Internal Revenue Service or the State taxing agency? 43 44 45 Did you or your spouse make any gifts to an individual that total more than $14,000, or any gifts to a trust? Were you or your spouse the beneficiary of COBRA premium assistance for any month during 2016? Did your bank account information change within the last twelve months? 2016 ESTIMATED TAXES PAID FEDERAL STATE Amt Paid Date Paid Amt Paid Date Paid Overpayment Applied From 2015 1ST Quarter Payment (Due 04/15/16) 2ND Quarter Payment (Due 06/15/16) 3RD Quarter Payment (Due 09/15/16) 4TH Quarter Payment (Due 01/16/17) APPLICATION OF OVERPAYMENT YES NO If you have an overpayment of taxes, do you want the excess refunded? Or applied to your 2017 estimates? DIRECT DEPOSIT OF REFUND Direct Deposit of Federal or State Tax Refund into Bank Account? (YES/NO) Name of Bank Routing Transit Number (9 digit # beginning with 01 thru 12 or 21 thru 32) Depositor Account Number (up to 17 characters) Type of account: Savings or Checking 2016 ESTIMATED TAX INFORMATION YES NO Do you expect your 2017 taxable income to be different from 2016? If "Yes" explain the differences in income, deductions, dependents, etc: Do you expect your 2017 withholdings to be different from 2016? If "Yes" explain any differences: MISCELLANEOUS INCOME - Attach ALL 1099-G, 1099-MISC, SSA-1099, 1099-B, 1099-S, and RRB-1099 forms. 1099-G - State Tax Refunds SSA-1099 (box 5) - Social Security Benefits SSA-1099 - Medicare Premiums Paid RRB-1099 (box 5) - Tier 1 RR retirement benefits 1099-G - Unemployment Compensation 1099-B - Sales of Stock (also include transaction history) 1099-S - Sales of real estate (also include closing statements) Alimony Received Taxable Scholarships and Fellowships Jury Duty Pay Household Employee Income not on W-2 Income from rental of personal property Excess minister's allowance 1099-MISC - Income Subject to S/E Tax: TAXPAYER SPOUSE 1099-MISC (box 3) - Other income:
ITEMIZED DEDUCTIONS MEDICAL AND DENTAL EXPENSES (Subject to AGI limits) PRESCRIPTION MEDICINES AND DRUGS DOCTORS, DENTISTS AND NURSES HOSPITALS AND NURSING HOMES INSURANCE PREMIUMS (excluding Long-Term Care & amounts paid with pre-tax dollars) LONG-TERM CARE PREMIUMS - taxpayer LONG-TERM CARE PREMIUMS - spouse INSURANCE REIMBURSEMENT (enter as a positive number) LODGING AND TRANSPORTATION: OUT-OF-POCKET EXPENSES NUMBER OF MEDICAL MILES DRIVEN OTHER MEDICAL AND DENTAL EXPENSES: TAXES PAID STATE AND LOCAL INCOME TAXES - Paid for prior yrs &/or to other states REAL ESTATE TAXES - PRINCIPAL RESIDENCE REAL ESTATE TAXES - PROPERTY HELD FOR INVESTMENT USE TAXES PAID ON 2016 PURCHASES USE TAXES PAID WITH 2015 STATE RETURN SALES TAX ON AUTOS NOT INCLUDED IN ABOVE STATE TAXES PAID ON VEHICLES, BOATS, AIRCRAFT & OTHER SPECIAL ITEMS PERSONAL PROPERTY TAXES (including Automobile/DMV fees) FOREIGN INCOME TAXES OTHER TAXES: INTEREST PAID HOME MORTGAGE INTEREST (Box 1) AND POINTS (Box 2) REPORTED ON FORM 1098: HOME MORTGAGE INTEREST NOT REPORTED ON FORM 1098 (If paid to the home seller, enter the seller's name, SSN or EIN, and address): POINTS NOT REPORTED ON FORM 1098: HOME MORTGAGE INSURANCE PREMIUMS INVESTMENT INTEREST: PASSIVE INTEREST: CASH CONTRIBUTIONS VOLUNTEER EXPENSES (Out-of-pocket) NUMBER OF CHARITABLE MILES CONTRIBUTIONS BY CASH OR CHECK (MUST include ALL receipts for donations):
ITEMIZED DEDUCTIONS (CONTINUED) NON-CASH CONTRIBUTIONS Please complete the information below for each donee. NAME OF CHARITABLE ORGANIZATION (DONEE) PROPERTY DESCRIPTION DATE OF DONATION (MM/DD/YY) DATE YOU ACQUIRED PROPERTY (MM/YY) HOW YOU ACQUIRED PROPERTY (Purchase, Gift, Inheritance, Exchange) YOUR COST OF THE PROPERTY Please provide us a detailed list of the donated items Provide a copy of the appraisal for non-cash contributions with a value over $5000 MISCELLANEOUS DEDUCTIONS (subject to 2% AGI limit) UNION AND PROFESSIONAL DUES OTHER UNREIMBURSED EMPLOYEE EXPENSES: INVESTMENT EXPENSE: TAX RETURN PREPARATION FEE SAFE DEPOSIT BOX RENTAL OTHER MISCELLANEOUS DEDUCTIONS (2% AGI): OTHER MISCELLANEOUS DEDUCTIONS GAMBLING LOSSES TO EXTENT OF WINNINGS: (Gambling winnings: ) (Gambling losses: ) OTHER MISCELLANEOUS DEDUCTIONS: ADJUSTMENTS TO INCOME ADJUSTMENTS TO INCOME TAXPAYER SELF-EMPLOYED HEALTH INSURANCE: TOTAL PREMIUMS (Excluding long-term care) LONG-TERM CARE PREMIUMS STUDENT LOAN INTEREST PAID (1098-E, box 1) EDUCATOR EXPENSES (Kindergarten thru Grade 12) TUITION AND RELATED EXPENSES JURY DUTY PAY GIVEN TO EMPLOYER EXPENSES FROM RENTAL OF PERSONAL PROPERTY ALIMONY PAID (First & Last Name, Recipient's SSN, and Amount paid): SPOUSE
RETIREMENT PLANS TAXPAYER SPOUSE KEOGH, SEP, PROFIT-SHARING, MONEY PURCHASE, AND SIMPLE CONTRIBUTIONS (Type of plan: ) (Plan contribution rate or amt: ) Employer matching rate for SIMPLE contributions (if not 3%) TRADITIONAL IRA (Maximum = $5500 / $6500 if 50 or older) Did you receive a distribution from a Traditional IRA or convert a Traditional IRA to a Roth IRA? ROTH IRA (Maximum = $5500 / $6500 if 50 or older) EDUCATIONAL IRA Have you considered contributing to an Educational IRA? (YES/NO) Would you like to discuss this issue with us? (YES/NO) CHILD AND DEPENDENT CARE EXPENSES TAXPAYER SPOUSE Dependent care expenses incurred but not paid in 2016 Employer-provided benefits forfeited in 2016 PERSONS OR ORGANIZATIONS PROVIDING CARE NAME OF PROVIDER #1 IDENTIFICATION NUMBER (SSN or EIN) TELEPHONE NUMBER (including Area Code) PAID TO CARE PROVIDER IN 2016: DEPENDENT #1 DEPENDENT #2 DEPENDENT #3 DEPENDENT #4 NAME OF DEPENDENT NAME OF PROVIDER #2 IDENTIFICATION NUMBER (SSN or EIN) TELEPHONE NUMBER (including Area Code) PAID TO CARE PROVIDER IN 2016: DEPENDENT #1 DEPENDENT #2 DEPENDENT #3 DEPENDENT #4 NAME OF DEPENDENT